Perioperative care in elective colonic surgery Enhanced Recovery After Surgery (ERAS) Society 2012 Guidelines

Muhammad Haris Aslam Janjua

Resident, Surgical Unit I

SIMS/Services Hospital, Lahore

Introduction• These guidelines represents the joint efforts of the

– ERAS Society, – International Association for Surgical Metabolism and Nutrition (IASMEN)

and – The European Society for Clinical Nutrition and Metabolism (ESPEN) to

present an updated and expanded consensus review of perioperative care for colonic surgery based on current evidence.

• The ERAS-care pathways reduce – surgical stress, – maintain postoperative physiological function,– enhance mobilisation after surgery.

• This has resulted in– reduced rates of morbidity, – faster recovery – shorter length of stay in hospital (LOSH)

1. Preadmission information, education and counselling

• Patients should routinely receive dedicated preoperative counselling

• Detailed information given to patients before the procedure about surgical and anaesthetic procedures may diminish fear and anxiety and enhance postoperative recovery and quicken hospital discharge

2.Preoperative optimisation

• Increasing exercise preoperatively may be of benefit.

• Smoking should be stopped 4 weeks before surgery

• Alcohol abusers should stop all alcohol consumption 4 weeks before surgery

3. Preoperative bowel preparation

• MBP should not be used routinely in colonic surgery.

• It can cause Dehydration and prolong post operative ileus

• MBP have a tendency towards a higher incidence of spillage of bowel contents, which might increase the rate of postoperative complications.

4.Preoperative fasting and carbohydrate treatment

• Clear fluids should be allowed up to 2 h and solids up to 6 h prior to induction of anaesthesia.

• In those patients were gastric emptying may be delayed (duodenal obstruction etc) specific safety measures should at the induction of anaesthesia.

• Preoperative oral carbohydrate treatment should be used routinely.

• In diabetic patients carbohydrate treatment can be given along with the diabetic medication.

5.Preanaesthetic medication

• Patients should not routinely receive long- or short-acting sedative medication before surgery because it delays immediate postoperative recovery.

• If necessary, short-acting intravenous drugs can be titrated carefully by the anaesthetist to facilitate the safe administration of epidural or spinal analgesia because these do not significantly affect recovery.

6.Prophylaxis against thromboembolism

• Patients should wear wellfitting compression stockings, have intermittent pneumatic compression, and receive pharmacological prophylaxis with LMWH.

• Extended prophylaxis for 28 days should be given to patients with colorectal cancer.

7.Antimicrobial prophylaxis and skin preparation

• Routine prophylaxis with intravenous antibiotics should be given 30-60 min before initiating colorectal surgery. Additional doses should be given during prolonged procedures according to the half-life of the drug used.

• Surgical-site infection was 40% lower in a concentration chlorhexidine-alcohol group than in a povidonee iodine group

8. Standard anaesthetic protocol

• A standard anaesthetic protocol allowing rapid awakening should be given.

• The anaesthetist should control fluid therapy, analgesia and haemodynamic changes to reduce the metabolic stress response.

• Mid-thoracic epidural blocks using local anaesthetics and low-dose opioids should be considered for open surgery.

• In laparoscopic surgery, spinal analgesia or morphine PCA is an alternative to epidural anaesthesia.

• If intravenous opioids are to be used the dose should be titrated to minimise the risk of unwanted effects.

9. Post Operative Nausea and Vomiting

• A multimodal approach to PONV prophylaxis should be adopted in all patients with 2 or more risk factors undergoing major colorectal surgery.

• If PONV is present, treatment should be given using a multimodal approach.

Risk factors

• Female patients, non-smokers and those with a history of motion sickness are at particular risk.

• The use of volatile anaesthetic agents, nitrous oxide and parenteral opiates increase the risk significantly.

• Major abdominal surgery for colorectal disease is associated with a high prevalence of PONV,

10.Laparoscopy and modifications of surgical access

• Laparoscopic surgery for colonic resections is recommended if the expertise is available.

• It decreases post operative pain, morbidity and Hospital stay

11.Nasogastric intubation

• Postoperative nasogastric tubes should not be used routinely. Nasogastric tubes inserted during surgery should be removed before reversal of anaesthesia

• Fever, atelectasis, and pneumonia are reduced in patients without a nasogastric tube

• There is no rationale for routine insertion of a nasogastric tube during elective colorectal surgery except to evacuate air that may have entered the stomach during ventilation by using a facial mask before endotracheal intubation.

12.Preventing intraoperative hypothermia

• Intraoperative maintenance of normothermia with a suitable warming device (such as forced air heating blankets, a warming mattress or circulating-water garment systems) and warmed intravenous fluids should be used routinely to keep body temperature >36 C.

• Temperature monitoring is essential to titrate warming devices and to avoid hyperpyrexia.

• Decreased temperative can lead to increased Post Op. Pain, morbid cardiac events, bleeding and infections.

13.Perioperative fluid management

• Balanced crystalloids should be preferred to 0.9% saline. In open surgery, patients should receive intraoperative fluids (colloids and crystalloids) guided by flow measurements to optimise cardiac output.

• Flow measurement should also be considered if: the patient is at high risk with comorbidities; if blood loss is >7 ml/kg; or in prolonged procedures.

13.Perioperative fluid management

• Vasopressors should be considered for intra- and postoperative management of epidural-induced hypotension provided the patient is normovolaemic.

• The enteral route for fluid postoperatively should be used as early as possible, and intravenous fluids should be discontinued as soon as is practicable.

13.Perioperative fluid management

• Fluid shifts should be minimised if possible by

– avoiding bowel preparation,

– maintaining hydration by giving oral preload up to 2 h before surgery,

– as well as minimising bowel handling and exteriorisation of the bowel outside the abdominal cavity

– avoiding blood loss.

14. Drainage of the peritoneal cavity after colonic anastomosis

• Routine drainage is discouraged because it is an unsupported intervention that probably impairs mobilisation

15. Urinary drainage

• Routine transurethral bladder drainage for 1-2 days is recommended.

16. Prevention of postoperative ileus (including use of postoperative laxatives)

• Mid-thoracic epidural analgesia and laparoscopic surgery should be utilised in colonic surgery if possible.

• Fluid overload and nasogastric decompression should be avoided.

• Chewing gum can be recommended, whereas oral administration of magnesium, bisacodyl and alvimopan (when using opioid-based analgesia) can be included.

17.Postoperative analgesia

• For open midline laparotomy, TEA is the optimal established analgesic technique.

• It offers superior analgesia in the first 72 h after surgery and earlier return of gut function provided the patient is not fluid-overloaded

• Using low-dose concentrations of local anaesthetic combined with a short-acting opiate appears to offer the best Combination.

17.Postoperative analgesia

• TEA using low-dose local anaesthetic and opioids should be used in open surgery.

• For breakthrough pain, titration to minimise the dose of opioids may be used.

• In laparoscopic surgery, an alternative to TEA is a carefully administered spinal analgesia with a low-dose, longacting opioid.

• In connection with TEA withdrawal, NSAIDs and Paracetamol should be used.

18. Perioperative nutritional care

• Patients should be screened for nutritional status and, if deemed to be at risk of undernutrition, given active nutritional support.

• For the standard ERAS patient, preoperative fasting should be minimised and postoperatively patients should be encouraged to take normal food as soon as possible after surgery .

• In ERAS, oral nutritional supplements (ONS) have been used on the day before surgery and for at least the first 4 postoperative days to achieve target intakes of energy and protein during the very early postoperative phase

19.Postoperative control of glucose

• Hyperglycaemia is a risk factor for complications and should therefore be avoided.

• Several interventions in the ERAS protocol affect insulin action/resistance, thereby improving glycaemic control with no risk of causing hypoglycemia.

• For ward-based patients, insulin should be used judiciously to maintain blood glucose as low as feasible with the available resources.

20. Early mobilisation

• Available RCTs do not support the direct beneficial clinical effects of postoperative mobilisation.

• Prolonged immobilisation, however, increases the risk of pneumonia, insulin resistance, and muscle weakness.

• Patients should therefore be mobilised.

• For more detailed study log on tohttp://www.espen.org/education/espen-guidelines